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Trump Orders Commission to Examine Opioid Addiction

New presidential commission continues the work of other government agencies to help fight opioid addiction and overdose now unfolding in rural and urban areas across the country.

Interviews with Steven Stanos, DO, Michael Hooten, MD, Edward Michna, MD, JD, RPH, and Kelly Pfeifer, MD

The war on the opioid-abuse epidemic does not seem to be waning. In his first 100 days, President Donald Trump issued an executive order creating the President’s Commission on Combating Drug Addiction and the Opioid Crisis1 and announced $485 million in grants to help states and territories combat opioid addiction.2

This action follows a similar move in New Jersey by Governor Chris Christie, who declared the opioid epidemic a public health crisis in his state. Gov. Christie has been tapped to head the new presidential commission.

As more guidelines unfold and state regulations evolve, keeping up with the challenge of eliminating the opioid-misuse epidemic while providing effective and compassionate care for legitimate pain patients is not easy for primary care physicians or pain specialists.

Positive Reaction to Commission Noted

As details of the commission emerge, reactions and responses have been favorable.

Steven Stanos, DO, president of the American Academy of Pain Medicine, is optimistic. "We want to make sure the commission is balanced, and appropriate care is not left out," he said in an interview with Practical Pain Management. He emphasized that the commission proceedings must not lead to loss of access to opioids for those patients who are taking the medications appropriately.  What's crucial, he added, is striking a balance to prevent abuse while ensuring that patients who need the medications can continue to get and take them.

The Academy ''has always been a proponent of multidisciplinary addiction treatment,'' said Dr. Stanos, who is medical director of Swedish Pain Services, Swedish Medical Center, Seattle, and a physiatrist. It's important to treat pain in a more comprehensive way, such as including psychological counseling, along with physical and occupational therapy, he noted.

The American Medical Association's board chair, Patrice Harris, MD, agreed. The AMA is ready ''to offer guidance in areas of effective public health approaches, best practices, clinical tools, medication-assisted treatment, and barriers to effective treatment," Dr. Harris said in a statement issued soon after the March announcement establishing the commission.

The emphasis, the AMA said, should be on the need to treat a substance use disorder as a medical illness, doing away with the stigma linked with seeking treatment for pain and for substance abuse.

Michael Hooten, MD, assistant professor of anesthesiology at Mayo Clinic Rochester, is hoping for bipartisan cooperation on the commission. He is a member-at-large on the board of directors for the American Academy of Pain Management and a member of the editorial board for Practical Pain Management.

"Regardless of the political environment, we must band together and work as a community and as a nation to help solve this horrible epidemic. It is clear with recent data we have not yet seen a plateau with accidental opioid-related deaths," he said.

How Bad Is the Opioid-Abuse Epidemic, Really?!

The epidemic has been termed ''unprecedented" by the US Department of Health and Human Services, noting on its website that more people died from accidental opioid drug overdoses in 2014 than any prior year on record.3 As the Centers for Disease Control and Prevention (CDC) reported in Morbidity & Mortality Weekly Report, drug overdoses claimed 47,000 lives that year.4 More than 6 of 10 of those cases involved an opioid.3

At the start of the opioid prescription boom, the addiction risk was believed to be minimal—claims of 1% of patients were reported, according to Kelly Pfeifer, MD, director of high value care for the California Health Care Foundation, a philanthropic organization devoted to identifying and solving health care problems, including the opioid epidemic. "Today we know that the percentage of people becoming addicted when taking opioids for pain is anywhere from 10% to 50%, not 1%," she said. And the length of time it may take to develop an addiction to opioids is startlingly brief, she said. While individual variations are great, there is a big jump up after taking opioids more than 5 days, 30 days, and 90 days.

Knowing your state regulations5 and prescription drug monitoring programs (PDMP)6 is crucial, as regulations vary greatly from state to state, said Edward Michna, MD, JD, RPH, assistant professor at Harvard Medical School and director of the Pain Trials Center at Brigham & Women's Hospital, Boston. To keep up with regulations, check your state board of medicine's website.

Longer, more frequent conversations with patients will be essential in combating the opioid tension, according to Dr. Pfeifer and Dr. Michna. Dr. Pfeifer suggested the need for genuine conversations with patients about managing their pain.

"We live in a society where people want instant gratification, instant relief," he said. They have unrealistic expectations of what the medical community can do for them. It's time clinicians level with patients to expect some pain. For example, a 70-year-old with severe arthritis should be helped to realize that painkillers wouldn’t eliminate spinal arthritis or restore his functionality back to the way he played golf at age 30.

"I ask patients what their expectations are about pain relief," Dr. Michna said. "Then, I set realistic expectations about what we can accomplish. I give them options and allow them to pick the most appropriate option for themselves."

One of the best changes that practitioners can make is to change the focus from pain scores to function, suggested Dr. Pfeifer. The goal of getting patients back to more normal functioning is really key, not simply lessening the pain, she said.

Present Alternatives

Recommending alternative treatments may not be 100% effective, Dr. Pfeifer said, but they can often help patients learn to cope with their pain, and sometimes can be adjuvant therapy to medical management.

As part of an American College of Physicians' Clinical Practice Guideline review, researchers examined medical literature from January 2008 through February 2016, to determine which non-drug therapies were deemed effective for low back pain, a common complaint. They found small to moderate benefits for:

  • Exercise
  • Psychological therapies
  • Multidisciplinary rehabilitation
  • Spinal manipulation
  • Massage
  • Acupuncture

The effects on pain, generally, were greater than the effects on functioning.

Dr. Michna reinforced the value of steering patients to nonopioid medications, such as an nonsteroidal anti-inflammatory drugs or neuropathic pain agents, and the importance of ongoing monitoring.

Regular check-ins with patients can go a long way to keeping them out of trouble, Dr. Michna said. In a patient at low risk for addiction, he may order a urine drug screen just once a year, as one way to monitor. For patients who show warning signs of misuse or abuse, an increase in the frequency of random urine drug testing is recommended.

Checking the state's PDMP report before prescribing an opioid is encouraged under the CDC opioid prescribing guidelines, but with limitations.7 One study found that most fatal overdoses could be identified retrospectively, on the basis of knowing about multiple prescribers and high total daily opioid dosage.6 However, the limited evaluation of the PDMP at state levels offered mixed results and effects on changes in prescribing and mortality outcomes.6

In San Francisco, the SF Department of Public Health slashed opioid-related emergency room visits by 50% by educating first responders about opioid overdose. One effective strategy was to include naloxone prescriptions for patients prescribed daily opioids.8

The authors confirmed no current financial conflicts.

Last updated on: March 29, 2019
Continue Reading:
Safe Use, Storage, and Disposal of Opioids

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